Summary: The care provider was at significant fault in the way it failed to provide a good standard of care and treatment for the late Mr X, and to maintain proper records about his care. The care provider has made service improvements since the events which took place here and offered a fee reduction to recognise the distress caused. The care provider agrees to offer an additional sum and provide full details of the service improvements it says it has put in place.

The complaint

1. Mrs A (as I shall call her) complains about poor care and treatment of her late father in the home. In particular she complains about poor personal hygiene care, failure to monitor and record falls, and delay in making appropriate referrals to the diabetic service and for palliative care.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I considered all the information provided by Mrs A and by the care provider. I spoke to Mrs A. Both Mrs A and the care provider now had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
7. Regulation 17 requires care providers to maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
8. Regulation 10 requires care providers to treat service users with dignity and respect.
9. Regulation 12 says care and treatment must be carried out in a safe way and must do everything practicable to mitigate risks.
10. In February 2023 the Ombudsman published guidance for care providers on good record keeping. We said “We are likely to find a care provider at fault where records are illegible or have clearly been changed after the event, where they are inadequate for their purpose, or where they omit essential information or include misleading information.”

What happened

11. Mr X was 96 when he moved from hospital to Northborne Care Home. Mrs A says she found a home for him near his friends so they could continue to visit him, although she lived some distance away. She says initially she was happy with the standard of care but after a series of staff departures, including the manager, she became aware of shortfalls in the care provided.
12. The pre-admission assessment carried out before Mr X moved into the home says he was not known to be at risk of falls. It also noted he had recently lost weight although there was no known reason. His food choices and intake were to be monitored because of his stoma and he was to be referred to the community team if the weight loss continued. He was also diabetic. He was described as ‘usually continent’ although Mrs A says he had been referred to the continence service prior to admission.
13. Mrs A says she began to have major concerns about the hygiene of Mr X’s room and the personal care provided to him. She says on occasions his bathroom and toilet were so dirty she cleaned it herself rather than leave it any longer. She says his clothes and particularly his slippers became encrusted with dropped food and dirt; his tray table was dirty and unhygienic and there was blood and faeces on the tiles in his bathroom. Mrs A says she asked the home manager to come with her to view the dining area which she says was also dirty and unhygienic, but the home manager refused.
14. In particular Mrs A says that although she had told staff that her father’s stoma bag should be changed every two days (usually when he had a shower) it was apparent that was not happening and Mr X became agitated because his stoma bag was frequently left full.
15. Mrs A says Mr X started to appear inappropriately dressed (clothes back to front or wearing a jumper without a shirt underneath), he was rarely showered – the records showed less than twice a month - and there was no proper record of his stoma bag changes.
16. Mr X began to fall frequently. In total he spent more than 5 weeks in hospital over 4 different periods as a result of falls. The home manager told Mrs A that her father had fallen 5 times between November 2022 and July 2023; however, the completed incident reports showed he had fallen 11 times. On one occasion Mr X suffered a minor stroke but the carer who was asked to attend to him said she was ‘on her break’ and refused to attend.

The complaint

17. Mrs A says in August 2023, after several unsatisfactory approaches to the care home manager, she complained formally to the care provider. She says it was only after this that the home contacted her about what it said were her father’s increasing needs. She said she agreed to a referral to palliative care but as far as she was aware this did not take place.
18. Mrs A travelled to the home on 10 August and spent the night in hospital with Mr X after another admission relating to a fall. She says the deputy home manager them asked her to go through Mr X’s care needs with her. Mrs A says she gained the impression that the staff had decided on a needs ‘figure’ above which Mr X would not be able to stay in the home and were determined to meet that figure despite the lack of professional input so far. The home manager then told her that Mr X could not stay at the home. Mrs A moved her father on 14 September directly from hospital, a day earlier than planned.
19. A regional manager responded in October 2023 to Mrs A’s complaints. She upheld or partially upheld the majority of Mrs A’s complaints. She said in some instances – for example the complaints about the frequency of stoma bag changes, GP visits, the number of falls, the lack of social activities– she found the concerns justified as the home had not been able to produce the records to evidence the correct care had been carried out. She said there should have been a post-falls analysis on each occasion but that only happened twice. She also said there was no evidence of referral to the diabetic service despite Mr X’s fluctuating weight, or the palliative care team.
20. The manager concluded she wanted to “sincerely apologise for the failings in our care for (Mr X) including but not limited to, elements of his personal care, lack of full care documentation, insufficient falls risk mitigation, social inclusion and not responding promptly to maintenance issues in his room”.
21. Mrs A says there was a ‘blatant disregard’ to managing Mr X’s safety while he was at the home. She says there were no falls sensors in his room despite paramedics telling the home there should have been. She says, ‘There is an absence of care & recording admitted by the investigator that contributed, in my view, to further falls & hospital admissions. On the 13th September, the ambulance service called me following a fall Dad sustained in the morning when he’d banged his head & cut his eyebrow. We agreed he was ‘safe’ to remain at NC given that he was being transferred to his new care home on Friday 15th September. Ambulance staff and I were assured by staff that they would monitor Dad closely. Later that evening Dad had another fall, wounding the back of his head & requiring another admission to hospital, Dad then moved to his new care home a day earlier following this fall’.
22. Mrs A says that eventually the care provider offered her the equivalent of one week’s fees (£1442) as a goodwill gesture. She says her father had spent 10 months at the home and had at least 10 hospital admissions during that time, spending 5 weeks in hospital, causing him considerable distress and causing her anxiety and stress seeking to resolve the issues.
23. The care provider has provided care records from March to September 2023. It says that during this time they were changing from paper records to an electronic system as it had recognised their paper records were not adequate. It says there were teething problems during this time. It maintains it did not fail to keep proper records ‘overall’ but accepts that in relation to Mr X, there was a lack of records relating to his personal care.
24. It says that the other key lessons learned as a result of this complaint were -

Ensure that full personal care is carried out and that records are maintained for these interactions, for example, shower/bath, appropriate clothing, personal aids such as working hearing aids.

Ensure that appropriate referrals to health professionals are made and reports obtained.

Ensure that falls are appropriately responded to mitigate the risk of further falls,for example, care plans and risk assessments reviewed, post falls analysis completed, referrals to health professionals made where appropriate.

Ensure that falls are checked appropriately when reviewing incident reports,i.e., review categories: Fall/Found on floor/Impact.

Ensure that there is a record of social activity engagement for each resident.

Ensure that urgent attention is given to maintenance issues which may directly impact on the resident.

Ensure that staff take breaks in staff rooms and not on the floor.

25. The care provider has provided details of the service improvements made, including record keeping, internal home inspections, ongoing training in key areas such as continence care, falls management and safeguarding.
26. Mrs A raised a safeguarding alert with the local council. Its investigation found there were failings in a number of areas, specifically continence management, falls risk management, stoma care, dietitian care, and the proper application of Deprivation of Liberty authorisations.

Analysis

27. The care provider failed to keep proper records for Mr X. That was a potential breach of the regulations. It also put him at further risk: without proper recording of the number and nature of falls it was not in a position to take action to prevent further incidents. The written records I have seen were narrative in nature, sometimes illegible and did not provide accurate detail of the care given.
28. The care provider failed to make appropriate referrals to other services, so Mr X did not receive the care he needed at the right time.
29. The care provider did not treat Mr X with dignity and respect. At times he was left dirty, in wet clothing and inexcusably with a full stoma bag.
30. The actions of the care provider caused distress and at times actual harm to Mr X, as well as causing considerable stress and anxiety for Mrs A.

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Agreed action

31. Mr X has died and the injustice to him cannot now be remedied.
32. Within one month of my final decision the care provider will provide me with a copy of its completed action plan for the last three months, a copy of the most recent internal inspection report from this home and minutes from the last three senior management team meetings.
33. Within one month of my final decision the care provider will apologise formally to Mrs A for the poor care and treatment of her father.
34. Within one month of my final decision, the care provider will make a payment equivalent to one month’s fees in recognition that the quality of care provided here fell below an acceptable standard.
35. Within one month of my final decision, the care provider will also offer £1000 to Mrs A to recognise the distress caused to her by its poor care and treatment of her father.
36. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

37. I have completed this investigation. I find that the actions of the care provider caused injustice to Mr X and Mrs A, which completion of the recommendations at paragraphs 32 – 35 will remedy.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman